Factors affecting outcome in schizophrenia and their relevance for psychopharmacological treatment

Demographic and clinical variables associated with response to clozapine in schizophrenia: a systematic review and meta-analysis

Clozapine is the only licensed pharmacotherapy for treatment-resistant schizophrenia. However, response to clozapine is variable. Understanding the demographic and clinical features associated with response to clozapine may be useful for patient stratification for clinical trials or for identifying patients for earlier initiation of clozapine. We systematically reviewed the literature to investigate clinical and demographic factors associated with variation in clozapine response in treatment-resistant patients with schizophrenia spectrum disorders. Subsequently, we performed a random-effects meta-analysis to evaluate differences in duration of illness, age at clozapine initiation, age of illness onset, body weight and years of education between clozapine responders and non-responders. Thirty-one articles were eligible for qualitative review and 17 of these were quantitatively reviewed. Shorter duration of illness, later illness onset, younger age at clozapine initiation, fewer hospitalisations and fewer antipsychotic trials prior to clozapine initiation showed a trend to be significantly associated with a better response to clozapine. Meta-analysis of seven studies, totalling 313 subjects, found that clozapine responders had a significantly shorter duration of illness compared to clozapine non-responders [g = 0.31; 95% confidence interval (CI) 0.06-0.56; p = 0.01]. The results imply that a delay in clozapine treatment may result in a poorer response and that a focus on prompt treatment with clozapine is warranted.

Can the Positive and Negative Syndrome scale (PANSS) differentiate treatment-resistant from non-treatment-resistant schizophrenia? A factor analytic investigation based on data from the Pattern cohort study

Treatment-Resistant Schizophrenia (TRS) and Non-Treatment-Resistant Schizophrenia (NTRS) may represent different subtypes of schizophrenia. However, few studies have investigated their PANSS symptom dimensions by Exploratory (EFA) or Confirmatory (CFA). Data from the present study are derived from 1429 patients of the Pattern study. TRS was defined by the use of clozapine in the previous year whereas NTRS by the use of non-clozapine antipsychotics ("by proxy"). Factors were chosen based on the Kaiser criterion and considered valid when loadings were greater than or equal to 0.5. The fit to the data was evaluated by CFA in comparison with well-established PANSS models, using fit indexes. The EFA yielded similar five-factor model in both groups: Negative, Positive, Anxiety/Depression, Cognitive and Excited. CFA showed a satisfactory, but not perfect, fit to the data, as compared with the previous PANSS factor analytic models. Despite the limitations regarding the 'by proxy' definition of TRS, the results of the present study show that there are no differences in the factorial structure of PANSS in patients with TRS and NTRS.

Evaluating the effectiveness of a culturally adapted behavioral family psycho-educational program for Egyptian patients with schizophrenia

Although a growing body of evidence supports the effectiveness of behavioral family therapies for patients with schizophrenia, few studies have been carried out on the effectiveness of such programs for Egyptian patients. The current study translated and culturally adapted the Behavioral Family Psycho-Education Program (BFPEP) and conducted a preliminary efficacy evaluation for outpatients suffering from schizophrenia. Thirty patients received 14 sessions of culturally adapted Program (CA-BFPEP) and 30 received treatment as usual; all were followed up for 6 months. Pre- and post-intervention assessment included primary outcome measures that assessed the clinical, social, quality of life and attitude towards medications. The CA-BFPEP group demonstrated significant treatment effects as they had greater reductions in psychotic symptoms (PANSS), improvement of social function (SFQ), quality of life (QoL), and attitude towards medications (DAI), compared to patients in the control group. These results demonstrate the feasibility of implementing family therapy interventions in different cultural settings with relatively minor modifications. These promising findings invite further efforts to maximize the benefits of family therapy interventions internationally and to encourage mental health policy makers to integrate this mode of therapy in routine care management plans for patients with schizophrenia.

Health service utilization and medical costs among patients with schizophrenia receiving long-acting injectable risperidone versus oral risperidone: a nationwide retrospective matched cohort study in Taiwan

The aim of the nationwide retrospective matched cohort study was to evaluate health service utilization and medical costs between patients with schizophrenia who received long-acting injectable (LAI) risperidone and those who took risperidone orally. Data were sourced from the 2008 to 2013 Psychiatric Inpatient Medical Claim Dataset in Taiwan. The sample selection process was performed by propensity score matching. Finally, there were 691 patients in the exposed cohort and 1382 patients in the unexposed cohort. Each patient was individually followed for a 1-year period. Two-part models and generalized estimating equations were used to evaluate health service utilization and direct medical costs of patients. Analytical results showed that patients receiving LAI risperidone had used outpatient services significantly more, had greater hospital admissions, and had shorter lengths of stay than those who took risperidone orally. Furthermore, compared with their counterparts in the unexposed group, patients in the exposed group had incurred higher medical costs because of costs incurred from increased utilization of outpatient service and hospital admissions, under the special context of the healthcare system in Taiwan, a single-payer universal health coverage system with low copayment rates. In summary, this study suggested that patients with schizophrenia treated with LAI risperidone had shorter lengths of stay, higher medical costs largely because of increased utilization of outpatient service and hospital admissions, compared with those who took risperidone orally.

Cognitive correlates of neuroimaging abnormalities in the onset of schizophrenia: A case report

Increasing evidence shows that cognitive impairment and brain abnormalities can appear early in the first episodes of schizophrenia, but it is currently debated how brain changes can correlate with clinical presentation of schizophrenic patients. Of note, this report describes the case of a young schizophrenic male presenting parietal magnetic resonance/positron emission tomography abnormalities and cognitive impairment, documented by specific neuropsychological tests. In our knowledge only few studies have investigated if neuropsychological abnormalities could be concomitant with both structural and functional neuroimaging. This case shows that impairment in specific cognitive domains is associated with structural/functional brain abnormalities in the corresponding brain areas (frontal and parietal lobes), supporting the hypothesis of disconnectivity, involving a failure to integrate anatomical and functional pathways. Future research would define the role of cognitive impairment and neurodegeneration in psychiatric nosography and, in particular, their role in the early phases of illness and long-term outcome of schizophrenic patients.

Factors associated with changes in hospitalisation in patients prescribed clozapine

OBJECTIVE

The objective of this study was to examine whether delays in clozapine treatment affect outcomes once clozapine is started and identify factors that affect these outcomes.

METHOD

Patients starting clozapine in a four year period at South London and the Maudsley NHS Foundation Trust were included. Clinical details were gathered from clinical notes. Primary outcome was net change in inpatient admissions comparing the periods before and after clozapine was started.

RESULTS

There was no significant association between the length of clozapine delay (mean clozapine delay = 3.93 years) and number or length of inpatient admissions once clozapine had been started (mean net change in days of admission = 16.74 days), F value = 0.901, p = 0.345. Clozapine reduced the total number of bed days per year, but only if treatment was continued - stopping resulted in inpatient admissions returning to pre-clozapine levels. Younger patients had a greater reduction in bed days when taking clozapine (p = 0.027).

CONCLUSION

Clozapine reduces the number of inpatient days, regardless of the chronicity of the illness at the time clozapine was started. Continued compliance with clozapine is necessary to maintain this benefit. Reduction in bed days is greater in younger patients, suggesting early initiation of clozapine may be beneficial.

A comparison of the effectiveness of risperidone, haloperidol and flupentixol long-acting injections in patients with schizophrenia--A nationwide study

BACKGROUND

Risperidone long-acting injection (RLAI), the first licensed, long-acting second-generation antipsychotic (SGA), has not yet been studied in terms of its effectiveness compared with first-generation antipsychotic (FGA) LAIs.

METHODS

The differences in the effectiveness of RLAI and two other FGA LAIs, haloperidol and flupentixol, were assessed by conducting a one-year pre-post study based on the Taiwanese National Health Insurance Research Database. Effectiveness was defined as reduced medical care utilization and relapse prevention.

RESULTS

A decreased number of relapses were identified in the haloperidol injection group in the post-LAI period than in the pre-LAI period (Wilcoxon signed rank test, p<0.05). The RLAI group had the largest number of acute admissions and relapses, the longest duration of admission (Wilcoxon signed rank test, p<0.005), and the lowest utilization of anticholinergic agents, such as benzodiazepine (BZD) and SGAs (except oral risperidone), among all of the LAI groups in the post-LAI period.

CONCLUSIONS

According to the results of this observational study, we suggest that the effectiveness of RLAI is not superior to that of FGA (haloperidol or flupentixol) LAIs, but that RLAI might have fewer adverse effects.

Clinical predictors of therapeutic response to antipsychotics in schizophrenia

The search for clinical outcome predictors for schizophrenia is as old as the field of psychiatry. However, despite a wealth of large, longitudinal studies into prognostic factors, only very few clinically useful outcome predictors have been identified. The goal of future treatment is to either affect modifiable risk factors, or use nonmodifiable factors to parse patients into therapeutically meaningful subgroups. Most clinical outcome predictors are nonspecific and/or nonmodifiable. Nonmodifiable predictors for poor odds of remission include male sex, younger age at disease onset, poor premorbid adjustment, and severe baseline psychopathology. Modifiable risk factors for poor therapeutic outcomes that clinicians can act upon include longer duration of untreated illness, nonadherence to antipsychotics, comorbidities (especially substance-use disorders), lack of early antipsychotic response, and lack of improvement with non-clozapine antipsychotics, predicting clozapine response. It is hoped that this limited capacity for prediction will improve as pathophysiological understanding increases and/or new treatments for specific aspects of schizophrenia become available.

Is duration of illness really influencing outcome in major psychoses?

BACKGROUND

An increasing number of studies identifies the duration of illness (DI) as an important predictor of outcome in patients affected by major psychoses (MP). The aim of the present paper was to revise medical literature about DI and its effects on MP, focusing in particular on the relationship between DI and outcome with particular reference to treatment response, suicidal risk, cognitive impairment and social functioning.

METHODS

A search in the main database sources has been performed to obtain a comprehensive overview. Studies with different methodologies (open and double-blinded) have been included, while papers considering other variables such as duration of untreated episode/illness were excluded. MP included the diagnoses of schizophrenia, bipolar disorder and major depressive disorder.

RESULTS

Available data show that DI influences treatment response, suicidal risk and loss of social functioning in schizophrenic patients, while results are more controversial with regard to cognitive impairment. In bipolar disorder, a long DI has been associated with less treatment response, more suicidal risk and cognitive impairment, but more data are needed to draw definitive conclusions. Finally, studies, regarding DI of illness and its predictive value of outcome in major depressive disorder show contradictory results.

CONCLUSIONS

DI appears a negative outcome factor particularly for schizophrenia, while with regard to mood disorders, more data are needed to draw definitive sound conclusions.

The effectiveness of cross-tapering switching to ziprasidone in patients with schizophrenia or schizoaffective disorder

OBJECTIVE

Switching antipsychotics is one useful therapeutic option when the treatment of schizophrenia encounters suboptimal efficacy and intolerability issues. This study aimed to investigate the efficacy and tolerability of cross-tapering switching to ziprasidone from other antipsychotics.

METHODS

A total of 67 patients with schizophrenia or schizoaffective disorder were recruited in this 12-week, multicenter, non-comparative, open-label trial. Prior antipsychotics were allowed to be maintained for up to 4 weeks during the titration of ziprasidone. Efficacy was primarily measured using the 18-item Brief Psychotic Rating Scale (BPRS) at baseline, 4 weeks, 8 weeks, and 12 weeks. Efficacy was secondarily measured by the Clinical Global Impression-Severity (CGI-S) scale and the Global Assessment of Functioning (GAF) scale at each visit. Regarding the metabolic effects of switching to ziprasidone, weight, body mass index (BMI), waist-to-hip ratio (WHR), and lipid profile-including triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and total cholesterol levels-were measured at each follow-up visit.

RESULTS

The BPRS scores were significantly improved at 12 weeks after switching to ziprasidone (F=5.96, df=2.11, p=0.003), whereas the CGI-S and GAF scores were not significantly changed. BMIs, WHRs, and TG levels were significantly decreased, with no significant changes in other lipid profiles.

CONCLUSION

Cross-tapering switching to ziprasidone is effective for patients with schizophrenia spectrum disorders. Beyond the efficacy of the procedure, favorable metabolic profiles show that switching to ziprasidone may be helpful for maintenance therapy over an extended period.

Reasons and clinical outcomes of antipsychotic treatment switch in outpatients with schizophrenia in real-life clinical settings: the ETOS observational study

BACKGROUND

Patients under antipsychotic treatment for schizophrenia commonly exhibit poor adherence to treatment, high rates of treatment discontinuation, and frequent treatment changes. The ETOS study aimed to identify the reasons leading physicians to decide to switch antipsychotic treatment in outpatients with schizophrenia and to evaluate the outcome of this switch.

METHODS

ETOS was an observational 18-week (four visits) study in outpatients 18 to 65 years old, diagnosed with schizophrenia according to Diagnostic and Statistical Manual of Mental Disorders - 4th edition criteria at least 6 months prior to enrolment, who were initiated on a new antipsychotic monotherapy treatment within the 2 weeks prior to enrollment. A total of 574 patients were recruited by 87 hospital- and office-based physicians. Ethical approval was obtained prior to study initiation (NCT00999895).

RESULTS

The final analysis included 568 patients, 39.0 ± 11.2 years old with mean disease duration of 11.7 years. The male-to-female ratio was 53:47. The main reason for switching antipsychotic treatment was lack of tolerability (n = 369, 65.0%), followed by lack of efficacy (n = 249, 43.8%). Following treatment switch, 87.9% of patients (n = 499) showed meaningful clinical benefit by achieving a Clinical Global Impression-Clinical Benefit score of ≤4 at the final visit. By the end of the study, total Positive and Negative Syndrome Scale, Clinical Global Impression-Improvement, Clinical Global Impression-Severity, and Simpson-Angus Scale scores demonstrated significant mean decreases of 31.69, 0.70, 1.14, and 11.30, respectively (all p < 0.0001). Treatment adherence remarkably improved.

CONCLUSION

In the ETOS study, switch of antipsychotic monotherapy for reasons relating to lack of efficacy and/or tolerability was associated with significantly improved clinical benefit and significant increase of patients' adherence to treatment.

Duration of untreated illness (DUI) and schizophrenia sub-types: a collaborative study between the universities of Milan and Moscow

BACKGROUND

Several studies show an association between a long duration of untreated illness (DUI) and poor outcome in schizophrenic patients. DUI, in turn, may be influenced by different variables including specific illness-related factors as well as access to local psychiatric services.

AIMS

The purposes of the present study were to detect differences in terms of DUI among schizophrenics coming from different geographic areas and to evaluate differences in DUI across diagnostic sub-types.

METHOD

One hundred and twenty-five (125) schizophrenic patients of the Psychiatric Clinic of Milan (n = 51) and Moscow (n = 74) were enrolled. SCID-I was administered to all patients and information about DUI was obtained by consulting clinical charts and health system databases, and by means of clinical interviews with patients and their relatives. DUI was defined as the time between the onset of illness and the administration of the first antipsychotic drug. One-way analyses of variance (ANOVAs) were performed to find eventual differences in terms of DUI across diagnostic sub-types.

RESULTS

Italian patients showed a longer DUI (M = 4.14 years, SD = 4.95) than Russians (M = 1.16 years, SD = 1.43) (F = 24.03, p < .001). DUI was found to be longer in paranoid schizophrenics (M = 3.47 years, SD = 4.19) compared to catatonic patients (M = 0.96 years, SD = 0.94) (F = 3.56, p = .016).

CONCLUSIONS

The results of the present study suggest that the different schizophrenic sub-types may differ in terms of DUI, likely due to different clinical severity and social functioning. Studies with larger samples are needed to confirm the data of the present study.

Can long-term outcomes be improved by shortening the duration of untreated illness in psychiatric disorders? A conceptual framework

The duration of untreated illness (DUI), meaning the latency to the pharmacological treatment, has been increasingly investigated in the last decade as a predictor of outcome across different psychiatric conditions, particularly in psychotic disorders. DUI is essentially computed by subtracting the age of onset of a specific disorder from the age at which the first adequate pharmacological treatment is administered. Assessment of the latency to treatment represents one of the first steps in planning early interventions. This review examines the role of the DUI in psychotic and affective disorders, focusing on neuropathological, epidemiologic, clinical and prognostic factors related to a longer latency to treatment. Through a Medline and Cochrane Library search, relevant studies up to June 2011 and other pertinent articles including meta-analyses, randomized controlled trials, naturalistic studies and clinical reviews were identified. Converging evidence indicates that a prolonged DUI negatively influences the outcome of first-episode psychosis and schizophrenia in different ways, and increasing data point toward a similar conclusion in affective disorders. Even though methodological limitations related to investigation of the DUI need to be considered, research and interventions aimed to reduce latency to treatments are object of increasing implementation worldwide. The assessment of the DUI represents one of the most important parameters to consider in this perspective, in order to quantify different latency to treatment in specific disorders and to plan related, targeted interventions.

Prominent clinical dimension, duration of illness and treatment response in schizophrenia: a naturalistic study

OBJECTIVE

Preliminary data indicate that predominant positive symptoms are predictive of subsequent treatment response, while negative and cognitive symptoms are associated with poor outcome. Purpose of the present study was to investigate the relation between the predominant clinical dimension, duration of illness and acute antipsychotic response in a sample of schizophrenic inpatients.

METHODS

Fifty-one schizophrenic inpatients, receiving an antipsychotic mono-therapy, were dimensionally assessed at the admission in the Acute Psychiatric Unit of the University of Milan. Treatment response was selected as parameter of outcome and defined as a reduction >50% of baseline total The Positive and Negative Syndrome Scale (PANSS) score. Demographic and clinical variables between responders and non-responders were compared using one-way analysis of variance for continuous variables and χ(2) test for dichotomous ones. Binary logistic regression was performed to find if dimensional scores and duration of illness were associated with acute antipsychotic response.

RESULTS

A longer duration of illness was found in non-responders respect to responders (15.61 years vs. 8.28 years)(F=4.98, p=0.03). Higher scores on PANSS positive sub-scale (OR=1.3, p=0.03), lower scores on cognitive PANSS scores (OR=0.75, p=0.05) and shorter duration of illness (OR=0.93, p=0.04) were found to be predictive of acute antipsychotic response.

CONCLUSION

These preliminary results show that a long duration of illness as well as a more severe cognitive impairment is predictive of treatment non-response, indicating a worse outcome for chronic patients with predominant cognitive symptoms.

Predictors of clozapine response in patients with treatment-refractory schizophrenia: results from a Danish Register Study

We aimed to identify factors associated with greater clozapine response to guide targeted clozapine use. The study was based on data from the Danish Psychiatric Central Research Register and the National Prescription Database including schizophrenia patients initiating clozapine from 1997 to 2006. Cox regression was used to identify predictors of time to psychiatric hospitalization and all-cause discontinuation from first clozapine prescription. In a 2-year mirror-image design, multiple logistic regression models were used to identify predictors of psychiatric hospitalization. Among 633 schizophrenia patients starting clozapine, shorter time to admission was predicted by increasing number of different antipsychotics (hazard ratio [HR], 1.08/trial; confidence interval [CI], 1.01-1.15/trial) and admissions (HR, 1.04/admission; CI, 1.03-1.05/admission) before first clozapine prescription, earlier onset of schizophrenia (HR, 0.98/y; CI, 0.96-0.99/y), and lower clozapine dose (HR, 0.07/100 mg; CI, 0.03-0.13/100 mg). In the 2-year mirror-image model, during clozapine treatment, there was a significant reduction in bed-days (269.9 days [CI, 238.3-287.8 days] to 64.2 days [CI, 53.0-79.3 days], P < 0.001) and admissions (3.4 [CI, 3.1-3.6] to 2.2 [CI, 1.9-2.5], P < 0.011). Being admitted during clozapine treatment was also associated with more antipsychotic trials (odds ratio [OR], 1.11; CI, 1.00-1.22) and admissions before clozapine initiation (OR, 1.08; CI, 1.04-1.11) and female sex (OR, 1.84; CI, 1.31-2.58). Although the study design does not allow any causal inferences, all 3 models suggested a lower number of psychiatric hospitalizations and antipsychotic trials before clozapine initiation to be associated with greater clozapine response.

A cost-consequence analysis of long-acting injectable risperidone in schizophrenia: a one-year mirror-image study with national claim-based database in Taiwan

OBJECTIVE

The development of long-acting atypical antipsychotics has provided a new paradigm for schizophrenia treatment. The economic effectiveness of risperidone long-acting injection (RLAI) on service costs has, however, never been studied in the real world with national claim-based database.

METHOD

To assess the change of service utilization and costs for schizophrenia before and after RLAI treatment, we conducted this 1-year mirror-image study with Taiwanese national claimed-data. Comparison was made for service sectors (the number of visits, acute admissions and relapse events) and cost components (outpatient, inpatient, emergency, medication and non-medication costs).

RESULTS

Service uses reduced in the post-RLAI period, along with a reduction of 34% and 32% on total inpatient services costs and inpatient non-medication costs, respectively (p < 0.005). However, overall psychiatric service costs went up by 26%, with an increase of 190% on total outpatient service costs and 177% on overall medication costs (p < 0.0001).

CONCLUSIONS

This 1-year mirror-image analysis showed that RLAI treatment was associated with reductions of service uses; however, overall psychiatric service costs were compromised by costs incurred from increased utilization of outpatient service and RLAI medication costs under the context of healthcare in Taiwan.

Descriptive analyses of the aripiprazole arm in the risperidone long-acting injectable versus quetiapine relapse prevention trial (ConstaTRE)

A recent randomized, open-label, relapse prevention trial (ConstaTRE) compared outcomes with risperidone long-acting injectable (RLAI) versus the oral atypical antipsychotic quetiapine. This study also included a small descriptive arm in which patients could also be randomized to aripiprazole. Results of this exploratory analysis are described here. Clinically stable adults with schizophrenia or schizoaffective disorder previously treated with oral risperidone, olanzapine, or an oral conventional antipsychotic were randomized to RLAI or aripiprazole. Efficacy and tolerability were monitored for up to 24 months. A total of 45 patients were treated with aripiprazole (10-30 mg/day) and 329 patients with RLAI (25-50 mg i.m. every 2 weeks). Relapse occurred in 27.3% (95% CI: 15.0-42.8%) of aripiprazole-treated and 16.5% (95% CI: 12.7-21.0%) of RLAI-treated patients. Kaplan-Meier estimates of mean (standard error) relapse-free period were 313.7 (20.4) days for aripiprazole and 607.1 (11.4) days for RLAI patients. Remission was achieved by 34.1% (95% CI: 20.5-49.9%) of aripiprazole and 51.1% (95% CI: 45.5-56.6%) of RLAI patients. Clinical global impression-change was improved ("minimally improved" to "very much improved") in 26.4% with RLAI and 15.9% with aripiprazole patients. Tolerability was generally good for both treatment groups. Weight gain (7.0% with RLAI vs. 4.4% with aripiprazole), extrapyramidal adverse events (AEs) (10.3% vs. 4.4%), and potentially prolactin-related AEs (4.6% vs. 0%) were more common with RLAI treatment, and gastrointestinal disorders were more common in aripiprazole-treated patients (22.2% vs. 6.1%). Time-to-relapse in stable patients with schizophrenia or schizoaffective disorder was numerically longer in RLAI-treated patients than in aripiprazole-treated patients although not statistically significant. Both treatments were generally well tolerated.

An epidemiologic and clinical overview of medical and psychopathological comorbidities in major psychoses

The presence of comorbidity in major psychoses (e.g., schizophrenia and psychotic subtypes of bipolar disorder and major depressive disorder) seems to be the rule rather than the exception in both DSM-IV and ICD-10. Examining comorbidity in major psychoses, however, requires an investigation into the different levels of comorbidity (either full-blown and subsyndromal) which should be analyzed in both psychopathological and medical fields. On one hand, the high prevalence of psychiatric comorbidity in major psychoses may be the result of the current nosographic systems. On the other hand, it may stem from a common neurobiological substrate. In fact, comorbid psychopathological conditions may share a biological vulnerability, given that dysfunction in specific brain areas may be responsible for different symptoms and syndromes. The high rates of comorbidity in major psychoses require targeted pharmacological treatments in order to effectively act on both the primary diagnosis and comorbid conditions. Nevertheless, few controlled trials in comorbid major psychoses had been carried out and treatment recommendations in this field have mostly an empirical basis. The aim of the present article is to provide a comprehensive and updated overview in relation to epidemiological and clinical issues of comorbidity in major psychoses.

Social outcome in clinically recovered first-episode schizophrenia in a naturalistic, ten-year, follow-up study in India

BACKGROUND

Remission of symptoms and clinical outcome seldom capture real-life outcome in schizophrenia. Measurement of social outcome provides a culturally meaningful indicator of how a patient is performing his or her role after recovery. The present study examined the status of social outcome on multidimensional parameters in a cohort of clinically recovered patients in a ten-year, long-term study of first-episode schizophrenia.

METHODS

First-episode hospitalized patients were recruited for a long-term outcome study. At the ten-year end point, those patients who showed good clinical outcome were assessed on culture-specific parameters of social outcome to find out the true nature of recovery in schizophrenia.

RESULTS

Sixty-one recovered patients showed differential outcome on various social parameters after ten years. Overall, 52.5% of patients showed good social recovery on all four social parameters. We found that 19 subjects (31.1%) were functioning socially satisfactorily, 10 subjects (16.4%) were productive in day-to-day life, 29 (48.3%) were economically independent, and 11 (18.3%) were satisfied with their education and new skills.

CONCLUSIONS

This study shows that not all patients who show clinical recovery have also improved in social functions on socially relevant parameters. Half of the patients continued to have limitations in the areas of social function (the ability to earn a sufficient income and conform to the expected social role). Social parameters need to be considered in everyday practice when defining outcome status.

Spirituality and religiousness as predictive factors of outcome in schizophrenia and schizo-affective disorders

Spirituality and religiousness have been shown to be highly prevalent in patients with schizophrenia. This study assesses the predictive value of helpful vs. harmful use of religion to cope with schizophrenia or schizo-affective disorder at 3 years. From an initial cohort of 115 outpatients, 80% were reassessed for positive, negative and general symptoms, clinical global impression, social adaptation and quality of life. For patients with helpful religion at baseline, the importance of spirituality was predictive of fewer negative symptoms, better clinical global impression, social functioning and quality of life. The frequencies of religious practices in community and support from religious community had no effect on outcome. For patients with harmful religion at baseline, no relationships were elicited. This result may be due to sample size. Indeed, helpful spiritual/religious coping concerns 83% of patients, whereas harmful spiritual/religious coping concerns only 14% of patients. Our study shows that helpful use of spirituality is predictive of a better outcome. Spirituality may facilitate recovery by providing resources for coping with symptoms. In some cases, however, spirituality and religiousness are a source of suffering. Helpful vs. harmful spiritual/religious coping appears to be of clinical significance.

Glutamate signaling in the pathophysiology and therapy of schizophrenia

Glutamatergic neurotransmission, particularly through the N-methyl-d-aspartate (NMDA) receptor, has drawn attention for its role in the pathophysiology of schizophrenia. This paper reviews the neurodevelopmental origin and genetic susceptibility of schizophrenia relevant to NMDA neurotransmission, and discusses the relationship between NMDA hypofunction and different domains of symptom in schizophrenia as well as putative treatment modality for the disorder. A series of clinical trials and a meta-analysis which compared currently available NMDA-enhancing agents suggests that glycine, d-serine, and sarcosine are more efficacious than d-cycloserine in improving the overall psychopathology of schizophrenia without side effect or safety concern. In addition, enhancing glutamatergic neurotransmission via activating the AMPA receptor, metabotropic glutamate receptor or inhibition of d-amino acid oxidase (DAO) is also reviewed. More studies are needed to determine the NMDA vulnerability in schizophrenia and to confirm the long-term efficacy, functional outcome, and safety of these NMDA-enhancing agents in schizophrenic patients, particularly those with refractory negative and cognitive symptoms, or serious adverse effects while taking the existing antipsychotic agents.

Emerging role of sertindole in the management of schizophrenia

The atypical antipsychotic sertindole is a phenylindole-derived compound that has affinity for and functions as an antagonist at a number of receptor systems, including dopamine D2 receptors, 5-HT(2A) and 5-HT(2C) receptors, and α-1-noradrenergic receptors. Although previous data suggested that sertindole was well tolerated and had good efficacy against both positive and negative symptom clusters, reports of QT prolongation with sertindole prompted its voluntary removal from the market in 1998. After further safety analyses, it recently regained approval and was reintroduced to the European market for the treatment of schizophrenia, where its role in therapy among available atypicals remains unclear. This article evaluates the preclinical and clinical data regarding sertindole's effectiveness and concludes that sertindole continues to demonstrate a number of strengths, including effective management of both positive and negative symptoms, well-tolerated side effects (including little or no sedation, weight gain, and extrapyramidal side effects), and a superior procognitive profile that is unique among atypical antipsychotics. However, minor concerns regarding its sexual side effects and the major consideration of QT prolongation suggest that additional comparative effectiveness studies are needed to determine the superiority of sertindole vs other atypical antipsychotics recently introduced.

Designing outcome studies to determine efficacy and safety of antipsychotics for 'real world' treatment of schizophrenia

Over the last 5 years, some studies have questioned the efficacy of second-generation antipsychotics over first-generation neuroleptics in the treatment of schizophrenia. At the same time, these study results have led to re-examination of their design--particularly CATIE and CUtLASS--which essentially measured relatively short-/mid-term outcome and did not always take into account real-world clinical practice and outcome measures (e.g. prevalence of positive acute symptoms, exclusion of comorbidity with substance abuse, predominance of chronic patients, lack of quality of life/wellbeing measures, etc.). In fact, one of the greatest challenges to treatment of schizophrenia is its life-long, multifaceted, functional disability associated with progressive cognitive deterioration after each acute episode. As such, the most important goal of the treatment is not just to deal with acute episodes, but rather to improve long-term outcome. Specifically, we aim for modest improvement and then stabilization of the different clinical dimensions involved in the overall symptomatology (i.e. negative/anergic, impulsive, positive, mood and cognitive impairments), and to achieve 'clinical stabilization' after obtaining a partial or full remission of acute symptoms, thus reducing the risk of a progressive cognitive deterioration. All these aspects need to be properly evaluated in a long-run perspective.

Duration of untreated psychosis and duration of untreated illness: new vistas

The duration of untreated illness (DUI), defined as the interval between the onset of a psychiatric disorder and the administration of the first pharmacological treatment, has been increasingly investigated in the last decade as a predictor of outcome across different psychiatric conditions including schizophrenia and psychotic disorders (duration of untreated psychosis), and mood and anxiety disorders. Converging evidence indicates that a prolonged DUI may be viewed as a negative prognostic factor in schizophrenia and increasing data point toward a similar conclusion in mood and anxiety disorders. Through a Medline search, the present article highlights the role of the DUI in this group of psychiatric disorders, focusing on social and psychopathological determinants of the DUI, as well as the clinical consequences related to a longer DUI in terms of outcome. Hypotheses on neurobiological mechanisms underpinning outcome differences in relation to a prolonged DUI are provided and methodological limitations related to the assessment of the DUI in published studies and clinical practice discussed. Finally, given that DUI is supposed to be a potentially modifiable prognostic factor, intervention programs aimed to reduce this variable are briefly considered and discussed.

Relapse and long-acting injectable risperidone: a 1-year mirror image study with a national claims database in Taiwan

OBJECTIVES

The development of long-acting, injectable atypical antipsychotics has provided a new paradigm for schizophrenia treatment. The study was designed to assess whether a risperidone long-acting injection (RLAI) is associated with reduced relapses and service utilization in the real world.

METHODS

The Psychiatric Inpatients Medical Claims dataset was used for the analysis. It is a longitudinal dataset that includes the National Health Insurance claims of service uses by a cohort of mentally ill patients. The inclusion criteria for this analysis were patients who: 1) had available information for at least 12 months after the first dose of RLAI; 2) had a primary diagnosis of schizophrenia; and 3) were regularly treated with RLAI for at least 1 year. Patients who accumulatively received at least 75-mg RLAI per 3-month period were considered to be undergoing regular treatment. Wilcoxon signed rank tests were performed to compare differences in numbers of acute admissions, hospital days, emergency room visits, and relapses between the pre- and post-RLAI periods in this 1-year mirror-image study.

RESULTS

In total, 108 patients were eligible for analysis. Significant reductions in the total annual numbers of acute hospital admissions by 55% (80 vs. 36, P = 0.0003), hospital days by 48% (4106 vs. 2126, P = 0.0021), and relapses by 54% (115 vs. 53, P = 0.0005) were observed. A reduction of emergency room visits was also observed, but did not reach statistical significance (55 vs. 25, P = 0.1255).

CONCLUSIONS

This 1-year mirror-image analysis with claims-based data demonstrated that RLAI treatment was associated with reductions in relapses and hospital service utilization.

Mood disorders and the outcome of suicidal thoughts and attempts

Suicidal ideation and attempts are common reasons for visits to the emergency department and critical care hospitalizations and a common public health problem. Most patients who make a suicide attempt have a psychiatric disorder, most frequently a mood, psychotic, substance use, or personality disorder. Patients who are at high risk of another attempt and cannot be transferred promptly to a psychiatric service should be managed jointly by the psychiatric and critical care teams with an emphasis on protection of the patient, identification of substance intoxication and withdrawal, making the environment safe, and instituting treatment of the psychiatric disorder. Antidepressants reduce suicide risk but their slow onset of action may make electroconvulsive therapy a desirable alternative for severely depressed patients. Parenteral treatment is possible with benzodiazepines and antipsychotic drugs but not antidepressants.

Importance of open access to atypical antipsychotics for the treatment of schizophrenia and bipolar disorder: a European perspective

OBJECTIVE

To assess European psychiatrists' prescribing behaviour and their perceived need for access to a wide range of atypical antipsychotics for patients with schizophrenia and bipolar disorder.

METHODS

A blinded, internet survey of psychiatrists from the UK, Germany, Italy and the Netherlands occurred in 2007. Key inclusion criteria for psychiatrists: practising full time; practising for 5-35 years; prescribed atypical antipsychotics in prior 6 months to > or =20 patients with schizophrenia or bipolar disorder. Eligible psychiatrists selected records for four patients with schizophrenia or bipolar disorder for whom they prescribed > or =1 atypical antipsychotic since January 2004.

RESULTS

Survey response rates were: UK, 14.8% (n = 107); Germany, 9.6% (n = 104); Italy, 8.9% (n = 101) and the Netherlands, 3.7% (n = 51); 363 psychiatrists reported on 1442 patients. Psychiatrists perceived a greater difference among atypical antipsychotics as a class (mean, 5.1 on a 7-point scale [7 = 'highly differentiated']) but not selective serotonin reuptake inhibitors (mean, 3.6). On average, psychiatrists used 6.8 different atypical antipsychotics across their patients with schizophrenia and 4.4 across their patients with bipolar disorder, with 2.5 and 2.4 changes required following first-line treatment to stabilise therapy, respectively. The most common reason for switching medication was lack of efficacy. Psychiatrists reported that expected consequences for patients should access to atypical antipsychotics be restricted would include illness deterioration, non-adherence and hospitalisation.

CONCLUSIONS

Although this study is limited by potential selection biases, these data suggest that European psychiatrists tailor antipsychotic medications for patients with schizophrenia or bipolar disorder according to patients' needs and specific drug attributes.

Differential diagnoses and management strategies in patients with schizophrenia and bipolar disorder

Successful treatment of psychiatric disorders, including bipolar disorder and schizophrenia, is complicated and is affected by a broad range of factors associated with the diagnosis, choice of treatment and social factors. In these patients, treatment management must focus on accurate and early diagnosis, to ensure that correct treatment is administered as soon as possible. In both disorders, the treatment of the disease in the acute phase must be maintained long term to provide continuous relief and normal function; the treatment choice in the early stages of the disease may impact on long-term outcomes. In schizophrenia, treatment non-compliance is an important issue, with up to 50% of patients discontinuing treatment for reasons as diverse as efficacy failure, social barriers, and more commonly, adverse events. Treatment non-compliance also remains an issue in bipolar disorder, as tolerability of mood stabilizers, especially lithium, is not always good, and combination treatments are frequent. In order to achieve an optimal outcome in which the patient continues with their medication life-long, treatment should be tailored to each individual, taking into account treatment and family history, and balancing efficacy with tolerability to maximize patient benefit and minimize the risk of discontinuation. These case studies illustrate how treatment should be monitored, tailored and often changed over time to meet these needs.